Archives of Gynecology and Obstetrics

, Volume 291, Issue 4, pp 907–915 | Cite as

Clinical relevance of objectifying colposcopy

  • Giuseppe F. Vercellino
  • Evrim ErdemogluEmail author
  • Vito Chiantera
  • Katharina Vasiljeva
  • Al-Hakeem Malak
  • Achim Schneider
  • Gerd Böhmer
Gynecologic Oncology



To evaluate the clinical value of four objective colposcopic criteria inner border, ridge sign, cuffed crypt openings and rag sign to diagnose cervical intraepithelial neoplasia grade 2 or worse (CIN 2+), using video exoscopy and to compare it to subjective graduating signs.


Retrospective evaluation of video recordings of 444 patients, referred for diagnostic colposcopy, who underwent cervical biopsies, and if indicated loop excisions. Most severe histological diagnosis was recorded. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LR) with 95 % confidence interval, for CIN 2+ were calculated.


Single biopsy, two biopsies and magnification-guided loop excision were performed in 60.8, 39.2 and 70.5 % of patients, respectively. Sensitivity, specificity, PPV and NPV to detect CIN 2+ were 19.3, 99.2, 98.3 and 35.8 %, for inner border sign; 53.1, 93.5, 94.7 and 47.6 %, for ridge sign; 51.5, 84.9, 88.2, and 44.3 %, for cuffed crypt openings, and 40.7, 96.4, 96.1 and 42.5 %, for rag sign, respectively. The positive likelihood ratio (LR+) was 26.7 and the negative likelihood ratio (LR−) was 0.81, for inner border sign; 8.2 and 0.5, for ridge sign; 3.41 and 0.57 for cuffed crypt openings; and 11.3 and 0.62 for rag sign, respectively. 90 % of CIN 2+ had at least one objective sign. Combination of any two objective signs significantly increased the LR of the presence of CIN 2+, and was clinically superior to any combination of graduating signs.


Objective colposcopic criteria are clinically useful and significantly associated with CIN 2+.


High grade cervical intraepithelial neoplasia Colposcopy Exoscopy Objective signs 



The authors thank Rita Maier for data collection. We dedicate this article to AnnelieseJähn 1932–2012 who dedicated her professional career to the prevention of cervical cancer at Charité University Medicine, Berlin, Germany.

Conflict of interest

Achim Schneider acts as advisor for Karl Storz, GSK and Sanofi Pasteur. He received honoraria for lectures.

Supplementary material

Supplementary material 1 (MOV 17166 kb)

Supplementary material 2 (MOV 55294 kb)

Supplementary material 3 (MOV 55332 kb)


  1. 1.
    Mayrand MH, Duarte-Franco E, Rodrigues I, Canadian Cervical Cancer Screening Trial Study Group et al (2007) Human papillomavirus DNA versus Papanicolaou screening tests for cervical cancer. N Engl J Med 357:1579–1588CrossRefPubMedGoogle Scholar
  2. 2.
    Schmidt D, Bergeron C, Denton KJ, European CINtec Cytology Study Group et al (2011) p16/ki-67 dual-stain cytology in the triage of ASCUS and LSIL papanicolaou cytology: results from the European equivocal or mildly abnormal Papanicolaou cytology study. Cancer Cytopathol 119:158–166CrossRefPubMedGoogle Scholar
  3. 3.
    Arbyn M, Roelens J, Simoens C et al (2013) Human papillomavirus testing versus repeat cytology for triage of minor cytological cervical lesions. Cochrane Database Syst Rev 28(3):CD008054. doi: 10.1002/14651858.CD008054.pub2.i-153 Google Scholar
  4. 4.
    Rijkaart DC, Berkhof J, Rozendaal L et al (2012) Human papillomavirus testing for the detection of high-grade cervical intraepithelial neoplasia and cancer: final results of the POBASCAM randomised controlled trial. Lancet Oncol 13:78–88CrossRefPubMedGoogle Scholar
  5. 5.
    Massad LS, Einstein MH, Huh WK, 2012 ASCCP Consensus Guidelines Conference et al (2013) 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol 121:829–846CrossRefPubMedGoogle Scholar
  6. 6.
    Arbyn M, Roelens J, Cuschieri K et al (2013) The APTIMA HPV assay versus the Hybrid Capture 2 test in triage of women with ASC-US or LSIL cervical cytology: a meta-analysis of the diagnostic accuracy. Int J Cancer 132(1):101–108. doi: 10.1002/ijc.27636 (Epub2012 Jun 13)CrossRefPubMedGoogle Scholar
  7. 7.
    Kitchener HC, Almonte M, Thomson C et al (2009) HPV testing in combination with liquid-based cytology in primary cervical screening (ARTISTIC): a randomised controlled trial. Lancet Oncol 10:672–682CrossRefPubMedGoogle Scholar
  8. 8.
    Ronco G, Giorgi-Rossi P, Carozzi F, New Technologies for Cervical Cancer screening (NTCC) Working Group et al (2010) Efficacy of human papillomavirus testing for the detection of invasive cervical cancers and cervical intraepithelial neoplasia: a randomised controlled trial. Lancet Oncol 11:249–257CrossRefPubMedGoogle Scholar
  9. 9.
    Katki HA, Kinney WK, Fetterman B et al (2011) Cervical cancer risk for women undergoing concurrent testing for human papillomavirus and cervical cytology: a population-based study in routine clinical practice. Lancet Oncol 12:663–672CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Mitchell MF, Schottenfeld D, Tortolero-Luna G et al (1998) Colposcopy for the diagnosis of squamous intraepithelial lesions: a meta-analysis. Obstet Gynecol 91:626–631CrossRefPubMedGoogle Scholar
  11. 11.
    Ferris DG, Litaker MS (2006) Prediction of cervical histologic results using an abbreviated Reid Colposcopic Index during ALTS. Am J ObstetGynecol 194:704–710CrossRefGoogle Scholar
  12. 12.
    Sellors JW, Nieminen P, Vesterinen E et al (1990) Observer variability in the scoring of colpophotographs. Obstet Gynecol 76:1006–1008PubMedGoogle Scholar
  13. 13.
    Kyrgiou M, Tsoumpou I, Vrekoussis T et al (2006) The up-to-date evidence on colposcopy practice and treatment of cervical intraepithelial neoplasia: the Cochrane colposcopy & cervical cytopathology collaborative group (C5 group) approach. Cancer Treat Rev 32:516–523CrossRefPubMedGoogle Scholar
  14. 14.
    Leeson SC, Alibegashvili T, Arbyn M et al (2013) The future role for colposcopy in Europe. J Low Genit Tract Dis 18(1):70–78 CrossRefGoogle Scholar
  15. 15.
    Cantor SB, Cárdenas-Turanzas M, Cox DD et al (2008) Accuracy of colposcopy in the diagnostic setting compared with the screening setting. Obstet Gynecol 111:7–14CrossRefPubMedGoogle Scholar
  16. 16.
    Pretorius RG, Zhang WH, Belinson JL, Huang MN et al (2004) Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of cervical intraepithelial neoplasia II or worse. Am J Obstet Gynecol 191:430–434CrossRefPubMedGoogle Scholar
  17. 17.
    Moss EL, Hadden P, Douce G et al (2012) Is the colposcopically directed punch biopsy a reliable diagnostic test in women with minor cytological lesions? J Low Genit Tract Dis 16:421–426CrossRefPubMedGoogle Scholar
  18. 18.
    Gage JC, Hanson VW, Abbey K et al (2006) Number of cervical biopsies and sensitivity of colposcopy. Obstet Gynecol 108:264–272CrossRefPubMedGoogle Scholar
  19. 19.
    Pretorius RG, Belinson JL, Azizi F et al (2012) Utility of random cervical biopsy and endocervical curettage in a low-risk population. J Low Genit Tract Dis 16:333–338CrossRefPubMedGoogle Scholar
  20. 20.
    Nam K, Chung S, Kwak J et al (2010) Random biopsy after colposcopy-directed biopsy improves the diagnosis of cervical intraepithelial neoplasia grade 2 or worse. J Low Genit Tract Dis 14:346–351CrossRefPubMedGoogle Scholar
  21. 21.
    Ihonor AO, Cheung WY, Freites ON (1999) A comparative study of the assessment of cervical intraepithelial neoplasia in women having large loop excision of the transformation zone. J Obstet Gynaecol 19:169–171CrossRefPubMedGoogle Scholar
  22. 22.
    Bornstein J, Bentley J, Bösze P et al (2012) 2011 colposcopic terminology of the international federation for cervical pathology and colposcopy. Obstet Gynecol 120:166–172CrossRefPubMedGoogle Scholar
  23. 23.
    Scheungraber C, Glutig K, Fechtel B et al (2008) Inner border—a specific and significant colposcopic sign for moderate or severe dysplasia (cervical intraepithelial neoplasia 2 or 3). J Low Genit Tract Dis 13:1–4CrossRefGoogle Scholar
  24. 24.
    Scheungraber C, Koenig U, Fechtel B et al (2008) The colposcopic feature ridge sign is associated with the presence of cervical intraepithelial neoplasia 2/3 and human papillomavirus 16 in young women. J Low Genit Tract Dis 13:13–16CrossRefGoogle Scholar
  25. 25.
    Vercellino GF, Erdemoglu E, Chiantera V et al (2013) Validity of the colposcopic criteria inner border, ridge sign and rag sign for detection of high-grade cervical intraepithelial neoplasia. Obstet Gynecol 121:624–631CrossRefPubMedGoogle Scholar
  26. 26.
    Dexeus S, Cararach M, Dexeus D et al (2002) The role of colposcopy in modern gynecology. Eur J Gynaecol Oncol 23:269–277PubMedGoogle Scholar
  27. 27.
    Vercellino GF, Erdemoglu E, Kyeyamwa S et al (2011) Evaluation of the VITOM in digital high-definition video exocolposcopy. J Low Genit Tract Dis 15:292–295CrossRefPubMedGoogle Scholar
  28. 28.
    Walker P, Dexeus S, De Palo G et al (2003) International terminology of colposcopy: an updated report from the International Federation for Cervical Pathology and Colposcopy. Obstet Gynecol 101:175–177CrossRefPubMedGoogle Scholar
  29. 29.
    Hopman EH, Kenemans P, Helmerhorst TJ (1998) Positive predictive rate of colposcopic examination of the cervix uteri: an overview of literature. Obstet Gynecol Surv 53:97–106CrossRefPubMedGoogle Scholar
  30. 30.
    Zahm DM, Nindl I, Greinke C et al (1998) Colposcopic appearance of cervical intraepithelial neoplasia is age dependent. Am J Obstet Gynecol 179:1298–1304CrossRefPubMedGoogle Scholar
  31. 31.
    Vercellino GF, Chiantera V, Gaßmann J et al (2012) Prospective comparison of loop excision under colposcopic guidance vs VITOM guidance. Geburtshilfe Frauenheilkd 72:945–948CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Crum CP (1993) Papillomavirus-related changes and premalignant and malignant squamous lesions of the uterine cervix. In: Clement PB, Young RH (eds) Tumors and tumorlike lesions of the uterine corpus and cervix. Churchill Livingstone, New York, pp 51–83Google Scholar
  33. 33.
    Ostör AG (1993) Natural history of cervical intraepithelial neoplasia: a critical review. Int J Gynecol Pathol 12:186–192CrossRefPubMedGoogle Scholar
  34. 34.
    Holowaty P, Miller AB, Rohan T, To T (1999) Natural history of dysplasia of the uterine cervix. J Natl Cancer Inst 3(91):252–258CrossRefGoogle Scholar
  35. 35.
    Moscicki AB, Shiboski S, Hills NK et al (2004) Regression of low-grade squamous intraepithelial lesions in young women. Lancet 364:1678–1683CrossRefPubMedGoogle Scholar
  36. 36.
    Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Prendiville W, Paraskevaidis E (2006) Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet 11(367):489–498CrossRefGoogle Scholar
  37. 37.
    Prendiville W (2009) The treatment of CIN: what are the risks? Cytopathology 20:145–153CrossRefPubMedGoogle Scholar
  38. 38.
    Biggerstaff BJ (2000) Comparing diagnostic tests: a simple graphic using likelihood ratios. Stat Med 19:649–663CrossRefPubMedGoogle Scholar
  39. 39.
    Simel DL, Samsa GP, Matchar DB (1991) Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol 44:763–770CrossRefPubMedGoogle Scholar
  40. 40.
    Etherington IJ, Dunn J, Shafi MI, Smith T, Luesley DM (1997) Video colpography: a new technique for secondary cervical screening. Br J Obstet Gynaecol 104:150–153CrossRefPubMedGoogle Scholar
  41. 41.
    Reid R, Scalzi P (1985) Genital warts and cervical cancer. VII. An improved colposcopic index for differentiating benign papillomaviral infections from high-grade cervical intraepithelial neoplasia. Am J Obstet Gynecol 153:611–618CrossRefPubMedGoogle Scholar
  42. 42.
    Coppleson M (1987) Colposcopic features of papillomaviral infection and premalignancy in the female lower genital tract. Obstet Gynecol Clin North Am 14:471–494PubMedGoogle Scholar
  43. 43.
    Massad LS, Jeronimo J, Katki HA, Schiffman M (2009) The accuracy of colposcopic grading for detection of high-grade cervical intraepithelial neoplasia. J Lower Genit Tract Dis 13:137–144CrossRefGoogle Scholar
  44. 44.
    Sideri M, Spolti N, Spinaci L et al (2004) Interobserver variability of colposcopic interpretations and consistency with final histologic results. J Low Genit Tract Dis 8:212–216CrossRefPubMedGoogle Scholar
  45. 45.
    Slama J, Adamcova K, Dusek L, Sosna O, Cibula D (2013) Umbilication is a strong predictor of high-grade cervical intraepithelial neoplasia. J Low Genit Tract Dis 17:303–307CrossRefPubMedGoogle Scholar
  46. 46.
    Hopman EH, Voorhorst FJ, Kenemans P, Meyer CJ, Helmerhorst TJ (1995) Observer agreement on interpreting colposcopic images of CIN. Gynecol Oncol 58:206–209CrossRefPubMedGoogle Scholar
  47. 47.
    Livasy CA, Moore DT, Van Le L (2004) The clinical significance of a negative loop electrosurgical cone biopsy for high-grade dysplasia. Obstet Gynecol 104:250–254CrossRefPubMedGoogle Scholar
  48. 48.
    Nadim B, Beckmann M (2013) Do we perform too many procedures for cervical dysplasia in young women? J Low Genit Tract Dis 17(4):385–389CrossRefPubMedGoogle Scholar
  49. 49.
    Agramunt S, Checa MA, González-Comadrán M et al (2013) High-grade squamous intraepithelial lesion could be managed conservatively in women up to 25 years: results from a retrospective cohort study. J Low Genit Tract Dis 17(4):459–462CrossRefPubMedGoogle Scholar
  50. 50.
    McAllum B, Sykes PH, Sadler L, Macnab H, Simcock BJ, Mekhail AK (2011) Is the treatment of CIN 2 always necessary in women under 25 years old? Am J Obstet Gynecol 205(478):e1–e7PubMedGoogle Scholar
  51. 51.
    Bennet N (2013) Detection of other cancers during cervical cancer screening. Lancet Oncol 14:e49CrossRefPubMedGoogle Scholar
  52. 52.
    Autier P, Coibion M, Huet F, Grivegnee AR (1996) Transformation zone location and intraepithelial neoplasia of the cervix uteri. Br J Cancer 74:488–490CrossRefPubMedCentralPubMedGoogle Scholar
  53. 53.
    Kierkegaard O, Byralsen C, Hansen KC, Frandsen KH, Frydenberg M (1995) Association between colposcopic findings and histology in cervical lesions: the significance of the size of the lesion. Gynecol Oncol 57:66–71CrossRefPubMedGoogle Scholar
  54. 54.
    Shafi MI, Finn CB, Luesley DM, Jordan JA, Dunn J (1991) Lesion size and histology of atypical cervical transformation zone. Br J Obstet Gynaecol 98:490–492CrossRefPubMedGoogle Scholar
  55. 55.
    Underwood M, Arbyn M, Parry-Smith W et al (2012) Accuracy of colposcopy-directed punch biopsies: a systematic review and meta-analysis. BJOG 119:1293–1301CrossRefPubMedGoogle Scholar
  56. 56.
    Stoler MH, Vichnin MD, Ferenczy A, FUTURE I, II and III Investigators et al (2011) The accuracy of colposcopic biopsy: analyses from the placebo arm of the Gardasil clinical trials. Int J Cancer 15(128):1354–1362CrossRefGoogle Scholar
  57. 57.
    Moss E, Redman C, Arbyn M (2013) Accuracy of colposcopy-directed punch biopsies. BJOG 120:903. doi: 10.1111/1471-0528.12161 CrossRefPubMedGoogle Scholar
  58. 58.
    Petry KU, Luyten A, Scherbring S (2013) Accuracy of colposcopy management to detect CIN3 and invasive cancer in women with abnormal screening tests: results from a primary HPV screening project from 2006 to 2011 in Wolfsburg, Germany. Gynecol Oncol 128:282–287CrossRefPubMedGoogle Scholar
  59. 59.
    Moss EL, Arbyn M, Dollery E et al (2013) European Federation of Colposcopy quality standards Delphi consultation. Eur J Obstet Gynecol Reprod Biol 170:255–258CrossRefPubMedGoogle Scholar
  60. 60.
    Nazeer S, Shafi MI (2011) Objective perspective in colposcopy. Best Pract Res Clin Obstet Gynaecol 25:631–640CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Giuseppe F. Vercellino
    • 1
  • Evrim Erdemoglu
    • 2
    Email author
  • Vito Chiantera
    • 1
  • Katharina Vasiljeva
    • 3
  • Al-Hakeem Malak
    • 1
    • 4
  • Achim Schneider
    • 1
    • 3
  • Gerd Böhmer
    • 5
  1. 1.Department of Gynecology and Gynecologic OncologyCharite UniversityBerlinGermany
  2. 2.Department of Gynecologic Oncology, Faculty of MedicineSuleyman Demirel UniversityIspartaTurkey
  3. 3.Department of Gynecology and Gynecologic OncologyCharité-Campus CharitéMitteBerlinGermany
  4. 4.Gynecology DepartmentKing Saud University Medical CollegeRiyadhSaudi Arabia
  5. 5.Colposcopy Clinic Wagner StibbeBad MünderGermany

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